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A  N 


INAUGURAL  DISSERTATION 


PUERPERAL   FEVER. 


9:      i 


-:-  •-^^•":^^^,r^. 


V     #~:*  -    *** 


Of  5 

H53 


TO  THE 

Honourable  JOHN  JAY,  Efquire* 

Chief  Juftice  of  the  United  States, 
&c.  &c.  &c. 

WILLIAM  SAMUEL  JOHNSON,  LL.  XX 

Prefident  of  Columbia  College,  &c> 

JOHN  CHARLTON, 

Prefident  of  the  Medical  Society  of  the  State  of 

New-York  i 

This  DifTertation  is  further  refpe&fully  inferibed, 

As  a  mark  of  regard  and  efteem, 

For  the  attention  fhewn  to  their  very  much  obliged 

Friend  and  humble  Servant, 

The  AUTHOR, 


X  O 


The  Right  Reverend 

SAMUEL   SEABURY,   D.  D. 

Bifhop  of  Connecticut  and  Rhode-Ifland: 


1  HIS  Diflertation  is  refpectfully  dedicated,  as  a  mark  of  that 
gratitude  and  efteem  which  the  Author  muft  ever  have  for 
the  Perfon  who,  in  the  mod  kind  and  friendly  manner,  directed 
him  in  his  Medical  Studies,  during  the  time  devoted  to  that 
Science  under  his  instruction. 


AN 

INAUGURAL  DISSERTATION 

ON    THE 

PUERPERAL   FEVER. 


SUBMITTED  TO  THE  PUBLIC  EXAMINATION 
OF      THE 

FACULTY    OF    PHYSIC, 

UNDER   THE    AUTHORITY    OF    THE 

TRUSTEES  OF  COLUMBIA  COLLEGE, 

IN      THE 

STATE  OF  NEW-YORK ; 
WILLIAM  SAMUEL  JOHNSON,  LL.D.  Prefidcnt: 

FOR   THE   DEGREE    OF 

DOCTOR    OF   PHTSId 

ON  THE  FIFTH  DAY  OF  MAY,  1 795. 


By  TIMOTHY  FLETCHER  WETMORE, 


OF    NEW-YORK. 


Sitiui  fit  ancepi  remedium  experiri  quam  nullum. 

Celsus. 
Felix  qui  potult  rerura  cognofcere  caufas. 

Virg. 


NEW-  YORK: 

PRINTED    BY    T.  AND    J.  SWORDS, 

Printer!  to  the  Faculty  of  Phyfic  of  Columbia  College. 

-1795.- 


%M    *•»* 


"i     i 

c3^La  (l 


K"<x 


1.715" 


PREFACE. 


A  S  this  fever  has  been  obferved  in  all  ages,  and  has 
been  conjidered  to  be  and  aclually  is  one  of  the  moft 
dangerous  difeafes  incident  to  the  fair  fex\  and,  as 
many  authors  of  eminence  and  great  natural  genius 
and  erudition  have  bejlowed  much  time  in  inveftigat- 
ing  it,  with  a  view  of  determining  the  real  caufe,  and 
rendering  the  method  of  cure  more  certain ;  and  as  its 
nature  has  remained  to  the  prefent  time  a  fubjecl  of 
much  difpute  and  uncertainty;  for  neither  Leake, 
Denman,  Manning,  Hulme,  White,  Kirkland, 
Butter,  Young,  Johnfton,  and  other  learned  men 
before  alluded  to,  have  agreed  on,  nor  fully  determined 
the  nature,  caufe  and  method  of  cure  in  this  fatal 
difeafe : — //  cannot,  therefore,  be  expected  that  IJhould 
advance  any  thing  new  or  definitive  on  thefubjeft,  (this 
being  only  a  collegiate  exercife)  although  I  am  induced 
to  take  a  view  of  the  fame,  as  it  is  a  difeafe  that  often 
perplexes  Phy/icians,  and  defcrvedly  demands  their 
greatejl  attention.  For  this  purpofe  IJhall  endeavour 
to  collefl  and  bring  forward  the  moft  received  opinions, 
B  with 


(     io     ) 

with  fome  remarks  thereon,  in  hopes,  by  fo  doing,  1  Jhall 
not  only  fulfil  a  collegiate  duty,  but  excite  the  attention 
of  fome  future  candidate  to  this  wide  field  for  invefii- 
gation,  and  to  a  fubjecl  of  fuch  importance  to  the 
welfare  of  the  female  fex. 

The  critical  period  at  which  this  fever  takes  place, 
when  febrile  commotions  are  apt  to  be  excited  by  various 
caufes,  and  the  equivocal  fymptoms  which  accompany 
it  have  afforded  room  for  quefiioning  whether  it  be  ,a 
primary  or  fecondary  difeafe:  fome  writers  have  confi- 
dered  it  as  proceeding  entirely  from  inflammation  of 
the  inteftines,  uterus,  &c.  others  have  imagined  it  to 
he  the  confequence  of  an  ohflrucHon  to  the  fecretion  of 
milk,  while  the  greater  number  have  been  inclined  (for 
reafons  equally  if  not  more  plaufible)  to  impute  it  to  a 
fupprejjion  of  the  lochia.  If  this  fever  is  examined 
attentively,  according  to  its  natural  courfe,  and  inde- 
pendently of  the  accidental  concomitant  fymptoms  with 
which  it  is  not  effentially  connected,  it  may  fafely  be 
pronounced  a  primary  difeafe  of  a  particular  type,  and 
perhaps  not  the  necejfary  confequence  of  any  of  the 
taufes  above  mentioned. 


AN 


A  N 


INAUGURAL  DISSERTATION 


PUERPERAL   FEVER. 


HISTORY  OF  THE  DISEASE. 


a 


N  the  fecond  or  third  day  after  delivery  the 
fymptoms  of  Puerperal  Fever  ufually  begin  to  mew 
themfelves :  they  are  not  uniform  but  varied,  for 
there  have  been  inftances  where  they  have  come  on 
within  twenty-four  hours  after  birth,  and  others  of 
their  not  appearing  till  the  fourth  or  fifth  day,  and 
fometimes  later,  and  even  not  until  the  twelfth 
day  :*  it  is  commonly  preceded  by  a  violent  rigor, 
producing  a  CquCq  of  conftriclion  on  the  extreme 
parts  of  the  body,  followed  by  great  debility,-f- 
languor,  lamtude,  naufca,  and  other  fymptoms  not 
unlike  thofe  produced  in  the  cold  ftage  of  intermit- 
tent, which   is  fucceeded  by  heat :    at  this  time 

the 

•  Home.  -f-  Lcuke. 


(       12      ) 

the  head  is  fcarcely  ever  free  from  great  pain,  efpe= 
daily  in  the  fore  part  and  over  the  eyes.     In  its  early 
ftage  it  is  attended  with  figns  of  inflammation — great 
pain  is  felt  in  the  hypogaftric  region,  in  the  back, 
hips  and  pubes  efpecialiy,  accompanied  with  heat 
and  throbbing;,  which  is  afterwards  extended  more 
generally,  and  over  the  whole  abdomen  and  its  inte- 
guments, and  produces  the  moft  exquifite  fenfibility, 
fo  that  the  patient  cannot  bear  to  be  touched.     In 
the  mean  time  the  pulfe  is  fmall  and  flow,  but  after- 
wards becomes  more  quick,  although  fometimes,  in 
plethoric  patients,  it  is  hard  and  full.    Thefe  fymp- 
toms  are  generally  the  fame  from  the  beginning. 
The  pulfe,  after  fome  time,  becomes  more  diftincl:, 
full  and  perceptible— the  fkin  is  generally  hot  and 
dry :  a  change  in  the  quantity  and  quality  of  the  lo- 
chia now  takes  place,  with  a  troublefome  tenefmus— 
the  urine  is  voided  with  pain,  fmall  in  quantity  and 
high  coloured,  but  not  always  the  fame :  in  the  ad- 
vanced ftages  of  the  difeafe  it  deposits  a  dark  coloured 
fediment :  fometimes  the  lochia  undergoes  no  change, 
either  in  quantity  or  quality,  but  are  dark  coloured 
and  foetid,  and  at  other  times  they  altogether  difap- 
pear.     The  fecretion  of  milk  alfo  undergoes  fimilar 
changes :  in  fome  it  is  diminiihed  in  quantity — in 
others  it  continues  natural  through  the  whole  courfe 

of 


(     S3     ) 

of  the  difeafe,  and  even  to  within  a  fhort  time  of 
death. 

On  the  firft  attack  of  this  fever,  the  patient  is 
feized  with  a  vomiting  of  matter  fimilar  to  that  in 
cholera,  to  which  the  difeafe  bears  a  ftrong  refem- 
blance-,  and  when  this  fymptom  takes  place,  and 
towards  the  fatal  termination  of  the  complaint,  the 
vomiting  fomewhat  refembles  coffee  grounds  :  but 
inftead  of  this  fymptom,  there  is  fometimes  only  a 
naufea,  with  a  difagreeable  tafte  in  the  mouth — the 
abdomen  fwells  to  a  confiderable  fize,  and,  as  before 
obferved,  becomes  fufceptible  of  painful  fenfations 
on  the  flighted  impreflion.  If  preffure  is  made  be- 
tween the  ftomach  and  umbilical  region,  the  pain 
becomes  intolerable,  which  is  not  the  cafe  when 
lower  down.*  The  tongue  is  generally  dry,  though 
fometimes  moift  and  covered  with  a  thick  brownifh 
fur,  accompanied  with  great  thirft,  and  in  general 
has  a  better  appearance  in  the  beginning  than  mod 
fevers — the  function  of  refpiration  is  performed  with 
more  or  lefs  difficulty  foon  after  the  commencement 
of  the  difeafe,  attended  at  times  with  a  fonorous 
noife.  After  a  few  days  the  fymptoms  of  inflam- 
mation ufually  fubfide,  and  the  difeafe  acquires  a 
typhoid  comple&ion  ;  the  pain  in  the  abdomen,  dif- 
ficulty 

•  Lealcc. 


C     14     ) 

ficulty  of  breathing,  anxiety-'  and  oppreffion  about 
the  praecordia  increafe,  which  is  fucceeded  by  a 
bilious  and  putrid  diarrhea  that  fometimes  evolves 
contageous  miafm.*  This  diarrhoea  is  fometimes, 
though  not  always,  of  a  dangerous  and  obflinate 
nature,  accompanying  the  difeafe  through  all  its 
ilages;  and  I  am  of  opinion  with  the  celebrated 
Home,  that  this  affection  is  only  fymptomatic. 
Each  motion  to  Jiool  is  preceded  by  a  temporary 
increafe  of  pain,  which,  on  taking  place  (/.  e.  the 
fbol)  there  is  an  alleviation  of  the  fame ;  the  pa- 
tient naufeates  all  kinds  of  food  and  drink,  except 
thofe  which  are  cold  and  of  the  acidelous  kind.  In 
confequence  of  putrid  exhalations,  the  teeth  become 
covered  with  a  brown  or  blackifh  fordes  •,  at  length 
troublefome  hiccough  is  produced,  which  greatly 
exafperates  the  pain  of  the  abdomen,  petechia?,  vi- 
bices,  and  fometimes  a  miliary  eruption  alfo  ap- 
pears, firft  on  the  neck  and  breads,  and  afterwards 
fpreads  over  the  whole  body,  but  which  produces 
no  mitigation  of  the  difeafe.  The  patient,  through 
the  whole  courfe  of  the  complaint,  is  afflicted  with 
a  peculiar  anxiety  and  dejection  of  fpirits,  which 
now  becomes  increafed;  the  eyes  no  longer  retain 
their  ufual  brightnefs,  but  become  more  and  more 

languid, 

*  White. 


(     i5     ) 

languid,  and  are  funk  in  the  head :  if  at  any  time 
the  patient  falls  into  a  dofe,  and  mould  continue  fo 
for  a  length  of  time,  fhe  finds  herfelf  but  little 
refreshed :  during  thefe  dofes  the  eyes  remain  open, 
the  noftrils  become  enlarged,  the  face  is  commonly 
much  flufhed,  the  cheeks  appear  of  a  purplifh  red, 
and  fometimes  there  is  a  circumfcribed  red  fpot  on 
the  fame;  the  lips  turn  livid,  the  difcharges  of 
urine  and  Jiool  become  involuntary,  and  the  partial 
fvveats  which  now  take  place  mew  that  death  is  at 
hand.  About  this  time  the  abdomen  is  not  only 
greatly  fwelled,  but  begins  to  change  to  a  greenifh  or 
even  biackifh  colour  ;*  the  pains  of  which  entirely 
ceafe  a  few  hours  before  death,  which,  when  it 
takes  place,  is  at  different  periods  of  the  fever, 
but  moft  commonly  from  the  feventh  to  the  twelfth 
or  fourteenth  days,  from  which  perhaps  the  refe- 
rable patient  flatters  herfelf  with  hopes  of  recovery ; 
but  thefe  are  ill-grounded,  for  very  foon  fubfultus 
tendinum,  delirium,  and  hiccough  come  on,  and  death 
fpeedily  clofes  the  fcene. 

Such,  in  general,  is  the  courfe  of  the  Puerperal 
Fever,  the  fymptoms  of  which,  however,  maybe 
often  varied,  (as  I  before  obferved)  according  to 
the  conftitution  of  the  patient,  feafon  of  the  year, 

management 

*  Tiflbt. 


(  tf  ) 

management  of  nurfes,  the  degree  of  the  difeafe, 
and  its  earlier  or  later  invafion. 


APPEARANCES  ON  DISSECTION. 

FROM  the  appearances  on  dijfeffion  of  thofe 
who  have  died  of  this  difeafe,  the  caufes  of  their 
death  have  been  found  very  obfcure;  fome  relating, 
that  by  diflection  the  difeafe  feemed  to  depend 
on  inflammation,*  others  that  it  was  not.-f-  From 
either  of  which  opinions  we  cannot  determine  the 
real  feat  and  nature  of  the  difeafe.  On  making  an 
Incifion  into  the  abdomen,  a  very  offenlive  air  iflues 
forth,  followed  by  a  very  foetid  humour,  which  is 
fometimes  yellow  j  it  is  found  in  a  fluid  flate  in  a 
greater  or  lefs  quantity :  the  interlines  are  fome- 
times found  ruptured,  more  or  lefs  inflamed,  and 
at  times  proceeding  to  a  fuppuration  and  inclin- 
ing  to,  or  actually  feized  with  gangrene.  J  But 
this  does  not  appear  to  be  the  cafe,  as  obferved  by 
Home  \  for  he  afTerts  that  the  interlines  are  not  only 
a  little  but  univerfally  inflamed :  but  if  there  is  any 
diftinct  inflammation,  it  is  in  that  part  of  the 
omentum  which  joins  the  interlines,  for  it  has  been 
obferved  to  be  particularly  aifecl:ed.§     The  ovaria 

are 

•  Leake  and  Hulme.  -J-  Young,  &c. 

J  Leake  and  others.  §  Leake° 


(     *7     ) 

are  fometimes  found  inflamed,  and  in  an  indurated 
and  gangrenous  ftate  •*  the  abdominal  vifcera  are 
alio  found  to  be  affected  with  inflammation  and 
adhefions.  There  appears  to  be  fcarcely  any  change 
in  the  nature  and  condition  of  the  uterus,  although 
fome  have  aflerted  it.  The  inflammation  is  never 
apparently  abfent  in  this  difeafe;  for  even  the 
pleura  itfelf  has  not  been  found  free  from  the  fame, 
as  has  been  made  more  clearly  to  appear  by  the 
indefatigable  and  unerring  anatomiit  John  Hunter. 


PREDISPONENT  CAUSES. 

IT  evidently  appears  that  the  female  fyflem  un- 
dergoes great  changes  during  gejlation^  as  the 
naufea,  vomiting,  fvveliing  of  the  breafts,  and  every 
trifling  circumftance  affecting  or  disturbing  the  body- 
in  an  unufual  manner,  and  which  more  readily 
takes  place  during  parturition,  clearly  mews. 
To  prove  that  this  difpofition  to  irritation  chiefly 
favours  the  production  of  this  difeafe,  it  has  been 
advanced,-]-  that  pregnant  women  acting  as  nurfcs 
to  thofe  who  are  lying-in,  are  never  attacked  with 
this  complaint  until  after  parturition;  and  hence 
C  there 

•  Home  and  Med.  Ccfnm.  vol.  iv.  and  vii. 
f  Leake. 


there  is  no  room  of  doubting  that  pregnancy  and 
parturition  are  among  the  principle  caufes  which 
predifpofe  to  this  fever. 

The  putrid  appearances,  however,  which  this 
difeafe  fb  readily  aflumes,  affords  ground  to  fufpect 
a  vitiated  ftate  of  the  humours  to  be  the  predijpo- 
nent  caufe ;  for  it  is  generally  obferved  to  be  moft 
prevalent  in  unhealthy  perfons,  and  among  women 
of  weakly  and  fcorbutic  conftitutions. 


EXCITING  CAUSES. 

THESE  are  many  and  various;  the  principal 
and  moft  remarkable  during  pregnancy,  appear  to  be 
the  intemperate  ufe  of  fpirituous  liquors,  too  great 
fatigue,  or  total  want  of  exercife,  too  high  or  too 
low  living,  coftivenefs  or  the  reverfe,  excefs  of  joy 
or  grief,  a  moift  and  warm  atmofphere,  impreg- 
nated with  putrid  effluvia.  In  lying-in,  an  overheat- 
ed and  confined  air,  by  breathing  in  a  chamber  that 
Is  not  fufficiently  ventilated,  coftivenefs,  too  warm 
a  regimen,  obftructed  perfpiration,  violence  and 
too  great  hafte  in  feparating  the  placenta,  the  ab- 
domen being  too  much  conftridled  by  bandages, 
with  the  officious  interference  of  midwives,  every 
thing  which  produces  a  plethoric  diathefis,  the  too 

foon 


C    19    ) 

foon  and  too  frequent  ufe  of  animal  food,  fpirituous 
liquors,*  and  other  cordials.  On  the  other  hand,  the 
exciting  caufes  of  this  difeafe  may  be  the  too  long 
confinement  of  the  woman  to  her  bed,  contagion, 
or  putrid  effluvia,  which  is  fo  often  generated  in 
hofpitals  and  elfewhere,  with  every  thing  which. 
contributes  to  produce  fever,  (other  circumftances 
being  favourable  j)  exceffive  evacuations,  efpecially 
haemorrhages ;  and  finally,  the  abforption  of  acrid, 
bilious  or  putrid  matter  from  the  alimentary  canal, 
uterus  or  vagina:  thefe  caufes  being  fufficient  to 
produce  fuch  a  condition  in  the  body  as,  united 
with  the  predifponent  ones,  will  produce  the  difeafe. 
To  thefe  may  be  added  the  various  emotions  of 
the  mind,  as  fudden  frights,  &c.  for  all  thefe  (ef- 
pecially if  the  woman  be  predifpofed  to  the  difeafe) 
may  defervedly  be  reckoned  among  the  exciting 
caufes.  This  difeafe  may  alfo  be  produced  by  cer- 
tain changes  in  the  atmofphere,  which  elude  our 
refearches,  and  cannot  be  detected;  for,  if  prevailing 
as  an  epidemic,  it  acquires  new  ftrength,  and  be- 
comes 

*  A  remarkable  cafe  occurred  in  the  month  of  January  laft,  in  a 
healthy  woman,  aged  twenty-eight  years,  who  wjs  put  to  bed  of  her 
fecond  child,  the  labour  perfectly  r  atural,  and  Arcngth  but  little  diminifh- 
ed  ;  flie  was  directed  by  her  midwife  in  the  free  ufc  of  gin,  (the  weather 
being  cold,)  of  wkich  fhe  took  fcveral  pints.  The  excitement  was  fo  great 
at  to  produce  indirect  debility,  typhus  fever,  ;md  death.  The  collive 
flate  in  which  flic  wa>  differed  to  remain,  might  alone  have  produced 
r  tviR  without  the  aid  of  fpiiituous  liquors. 


(      20      ) 

comes  more  mortal.  It  is  more  frequent  in  hospi- 
tals than  other  places,  and  is  more  fatal  in  the  for- 
mer than  in  the  latter. 


PROXIMATE  CAUSE. 

I  HERE  feel  and  muft  confefs  my  inability  to 
produce  a  fufficient  explanation  of  the  real  nature 
and  caufe  of  this  difeafe,  which  will  be  in  any  man- 
ner fatisfactory  j  I  mail,  however,  take  a  concife 
view  of  the  moft  plaufible  opinions,  as  delivered 
by  the  mofr,  approved  authors,  and  endeavour  to 
examine  them  attentively,  according  to  their  re- 
fpedlive  merits,  with  fome  inferences  therefrom. 
The  opinions  concerning  the  immediate  caufe  of 
this  difeafe  may  be  reduced  to  three  heads : 

I.  The  fuppreffion  and  retention  of  the  lochia. 

II.  A  transfufion  of  the  milk. 

III.  An  inflammation  of  the  interlines  and  omen- 

tum. 
Moft  fluids,  after  being  retained  a  long  time  in 
their  refpective  vefTels,  receptacles  or  excretory 
duels,  become  acrid ;  it  was  fuppofed,  therefore, 
that  the  lochia  and  milk,  (for  fimilar  reafons)  when 
long  retained,  might  be  the  proximate  caufe  of 
this  fever-,  but  I  am  inclined  to  think  that  this 

feldom 


(      U      ) 

feldom  happens,  for  we  find  that  it  comes  on  much 
{boner  from  fuch  a  change  firfl  taking  place  in  the 
lochia  and  milk  -,  and  moreover,  it  has  often  arifen 
when  there  was  not  a  fufficient  caufe  (if  we  may 
reafon  from  thefe  data)  to  expect  its  attack.  That 
the  lochia  -*xm  not  always  nor  at  fixed  periods 
flow,  we  have  already  fhewn  in  the  hiftory  of  the 
difeafe  •,  for  at  one  time  they  do  not  vary  in  quantity 
or  quality,  but  continue  a  fufficient  time,  and  are 
of  a  good  kind :  at  another  time  they  are  fparing 
and  of  a  putrid  nature ;  and  oftentimes,  when  the 
difeafe  has  advanced,  they  are  almoft  fuppreffed; 
therefore  it  remains,  without  admitting  a  doubt, 
that  this  alone  can  by  no  means  be  a  fufficient  caufe 
to  produce  this  fever.  Nor  does  it  appear  more 
reafonable  to  afcribe  the  caufe  of  this  difeafe  to  a 
transfufion  of  the  milk,  for  whether  there  be  a 
transfufion  or  not,  the  occurrence  of  the  difeafe  is 
much  the  fame.  Nor  does  it  more  clearly  appear 
that  the  inflammation  of  the  interlines  and  omen- 
tum is  the  proximate  caufe  of  this  difeafe :  how- 
ever, this  opinion  ought  not  equally  with  the  others 
to  be  rejected:  thofe  efpecially  who  favour  this  lat- 
ter opinion  contend  that  the  uterus,  after  birth,  is 
fomewhat  inclined  to  be  contracted  •,  from  whence 
they  have  formed  their  opinion,  to  wit,  that  that 

organ 


C      22      } 

organ  Inclines  to  regain  its  former  figure  and  origi- 
nal ftate,  becaufe  the  blood  is  not  poured  into  it 
any  longer  in  fo  great  a  quantity  as  it  was  before, 
and  which  was  requisite  in  a  ftate  of  geftation. 
Hence,  fay  they,  the  blood  being  determined  to 
another  part,  rufhes  into  thofe  vefTels  which  make 
the  leaft  refinance,  to  wit,  thofe  of  the  omentum 
and  inteftines,  by  which  they  fuffer  a  preternatural 
diftention ;  and  this  diftention  or  congeftion  (in  the 
opinion  of  fome)  is  thought  to  be  the  origin  of 
this  difeafe :  but,  at  the  time  of  geftation  being 
gone  through,  and  the  birth  at  hand,  the  omentum 
has  been  found  wounded  when  nothing  like  this 
difeafe  has  followed.  From  hence  it  is  proved,  that 
puerperal  fever  is  not  always  the  confequence  of  a 
wound  in  the  omentum.* 

It  cannot  be  denied  that  this  fever  has  followed 
great  difcharges  from  the  womb,  which  fometimes 
happen  after  parturition:  this  being  the  cafe,  it 
can  fcarcely  be  fuppofed  that  the  vefTels  of  the 
omentum  can  then  be  fo  much  diftended  by  blood 
as  to  be  productive  of  this  fever.  And  if  it  is  al- 
lowed that  the  contractile  force  which  the  uterus 
porTefTes  is  greater  in  the  firft  pregnancies  than  thofe 
which  follow,  (for,  in  fad,  the  fudden  contraction  of 

the 

*  White,  p.  412. 


(   n   ) 

the  uterus  with  the  very  fmall,  if  any,  paiiis  which 
are  apt  to  follow  the  flrft:  parturition,  feem  to  favour 
the  opinion,)  is  not  this  fever  then  more  to  be  ex- 
pected in  thofe  who  ly-in  of  their  firft  children  ? 
Why  is  there  not  danger  alfo  that  this  fever  may 
follow  the  operation  of  the  paracentesis  ? 

Among  all  it  is  agreed,  that  the  fymptoms  ma- 
nifested in  this  difeafe  (producing  death)  are  the 
fame  which  take  place  in  putrid  fevers  :*  and  hence 
it  may  be  concluded,  that  nothing  determinate  can 
be  collected  as  to  the  real  feat  and  nature  of  the 
difeafe.  Sometimes,  in  various  parts  of  the  body, 
there  feems  to  be  a  certain  jomething  deposited, 
which  produces,  as  it  were,  a  crifis;  and  from  hence 
all  the  fymptoms  have  manifestly  grown  milder: 
but  examples  of  this  kind  are  rare,  nor  does  the 
difeafe  always  ceafe  on  fuch  a  deposition. 

Upon  a  comparative  view  of  thefe  opinions,  I 
think  the  one  of  congestion  in  the  blood  veSTeis  of 
the  omentum  and  interlines  producing  inflammation 
in  thefe  parts,  is  too  fanciful  and  too  much  favour- 
ing hypothecs  to  have  much  faith  placed  in  it: 
for  it  is  not  fufficiently  fupported,  nor  do  directions 
prove  the  fame. 

That  kind  of  eryfipelas  which  is  apt  to  appear 

on 

•  Sir  John  Pringlt,  Clcghorn  and  Lind. 


(     24     ) 

on  the  decline  of  this  fever,  ought  to  be  confidered 
as  fymptomatic  only. 

To  me  it  does  not  feem  improper  to  clafs  the 
puerperal  fever  among  thofe  difeafes  to  which  Dr. 
Cullen  has  given  the  name  of  fynochus ;  for  this  dif- 
eafe, as  far  as  I  am  able  to  judge,  does  not  differ 
from  fynochus,  except  in  its  attacking  lying-in  wo- 
men. That  this  opinion  is  not  far  from  being  right, 
the  attack,  progrefs  and  termination  of  .the  fever 
prove  -,  for,  generally,  in  the  beginning  it  is  at- 
tended with  fuch  manifeft  fymptoms  of  inflamma- 
tion as  to  refemble  fynocha,  and  then  evidently  re- 
quires blood-letting ;  but  in  the  courfe  of  one  •  or 
two  days  marks  of  afthenia  appear  over  the  whole 
body,  and  then  the  difeafe  refembles  typhus* 


DIAGNOSIS. 

THIS  difeafe  is  known  by  pyrexia,  accompa- 
nied with  great  inquietude  and  violent  acute  pains 
of  the  abdomen  below  the  ftomach;  for  on  preflure 
being  made  between  it  and  the  umbilical  region, 
the  forenefs  is  fo  great  as  not  to  bear  the  gentleft 
touch.  Thefe  pains  may  be  diftinguifhed  from 
thofe  called  after-pains,  by  their  uninterrupted  con- 
tinuance through  the  whole  courfe  of  the  difeafe, 

though 


£     25     ) 

though  fometimes  they  fuffer  exacerbations ;  where- 
as, in  the  latter,  they  often  wholly  intermit.  It  is 
known  by  a  dread  in  taking  a  full  infpiration,  which 
caufes  much  uneafinefs;  by  the  refpiration  being 
quick  and  fhort,  the  lungs  themfelves  not  appear- 
ing affected,  this  difficulty  increafing  with  the  dif- 
cafe;  by  flatulencies,  coftivenefs  or  the  reverfe. 

This  fever  may  be  diflinguifhed  from  the  miliary 
by  the  rigor  attending  it  being  more  violent,  of 
longer  duration,  and  not  interrupted  ;  the  pulfe  is 
fuller  and  ftronger,  the  fkin  more  hot  and  freer 
from  that  itching  fenfation  which  is  felt  in  the  mi- 
liary fever;  nor  do  the  eruptions  in  the  puerperal 
produce  a  crifis  as  they  generally  do  in  the  miliary 
fever;  and  the  tongue,  whether  moift  or  dryv 
(though  generally  the  latter)  is  not  of  a  white  but 
brownifh  appearance;  the  urine  is  alfo  higher  co- 
loured.  1  he  tsmmmtti  m  the  beginning  or  the 
puerperal  is  almoft  always  conftipated,  which  gives 
another  mean  of  diftinguiming  the  difeafe. 

In  the  byjleritis,  a  difeafe  that  favours  the  puer- 
peral, the  pain  is  only  felt  in  the  uterus  and  about 
the  private-parts;  but  in  the  puerperal  fever  the 
pains  are  felt  in  the  ftomach  and  inteftines :  nor  is 
the  patient  affected  in  the  beginning  of  this  difeafe 
D  with 


t  26  ) 

-with  violent  delirium ;  neither  is  the  os  uteri  fo  pain- 
ful when  touched  as  in  hyfteritis. 

To  diftinguifh  the  puerperal  fever  from  enteritis* 
the  pain  is  obferved  to  be  more  external,  nor  does 
it  affect  the  umbilical  region  only ;  neither  are  the 
bowels  fo  obftinately  conftipated  as  in  that  difeafe. 

When  the  original  attack  of  this  fever  happens 
to  coincide  with  febrile  commotions,  excited  in  child- 
i)ed  women  by  the  fecretion  of  milk,  the  nature  of 
it  may  at  firft  be  mifapprehended ;  but  the  conco- 
mitant fymptoms  and  great  violence  of  the  difeafe 
will,  in  a  fhort  time,  diffipate  fuch  an  error.  In 
the  milk  fever  the  breafts  are  ufually  tumified,  but 
in  the  puerperal  they  commonly  are  not;  nor  are 
thofe  pains  which  are  frequently  felt  mooting  from 
the  breafts  to  the  arms,  and  back  again3  in  the  milk 
fever3  felt  in  the  puerperal. 


PROGNOSIS, 

WHEN  the  patient  is  naturally  weak,  her 
ftrength  greatly  reduced  by  immoderate  evacuations 
after  parturition,  and  when  the  difeafe  is  violent, 
and  immediately  follows  delivery,  its  progrefs  and 
termination  are  proportionably  rapid  and  fatal:  in 
thefe  unfortunate  circumftanees  many  have  expired 

within 


(       27       ) 

within  twenty-four  hours  from  the  firfl:  attack  of 
the  difeafe;  and  there  have  been  fome  inftances- 
where  the  rigor  has  clofed  the  fcene :  however,  the 
cataftrophe  is  generally  fufpended  for  a  few  days ; 
but,  for  the  moft  part,   fomewhere  between  the 
fifth  and  eleventh,  from  the  commencement,  may 
be  fixed  on  as  the  decifive  period ;  but  if  it  mould 
be   protracted   beyond    the  eleventh   day,    there 
wHI  be  more  hopes  of  a  recovery,   although  it 
fometimes  happens  otherwife.     The  moil:  favour- 
able fymptoms  are  a  gentle  diarrhoea,  which  renders 
the  pains  lefs  acute ;  the  urine  depofiting  a  dark  co- 
loured fediment,  and  efpecially  if  the  lochia  begin 
again  to  flow,   after  being  fomewhat  fuppreffed, 
together  with  the  fecretion  of  milk  being  again  re- 
newed.    If  there  is  alfo  a  gradual  diminution  of 
the  fwelling,  pain,  and  forenefs  in  the  abdomen,  and 
if  after  the  bowels  have  been  opened  there  is  a 
gentle  diaphorefis  difFufed  over  the  whole  body, 
and  if  the  vomiting,    anorexia,   and  other  febrile 
fymptoms  begin  to  difappear-,  there  will  be  reafon 
to  hope  a  favourable  termination  of  the  difeafe. 
But  if,  on  the  other  hand,  the  fwelling  of  the  ab- 
domen does  not  fubfide  en  the  commencement  of 
the  diarrhoea  i   if  the  refpiration  is  alfo  attended 
with  a  fenfe  of  anxiety  and  ftricture  in. the  thorax; 

if' 


(     28     ) 

if  the  ftrength  is  very  much  reduced,  and  at  thefama 
time  petechia  appear,  and  the  excrements  are  black 
and  foetid,  it  is  evident  the  patient  is  in  imminent 
danger : — if  the  pains  in  the  abdomen  entirely  ceafe, 
thepulfes  become  fo  very  fmall  and  frequent,  that  they 
cannot  be  numbered ;  if  involuntary  difcharges  of 
the  foeces  by  ftool ;  if  a  greenifh  or  blackifh  matter 
is  ejected  by  vomiting ;  vifcid  eold  fweats  affect  the 
extremities,  and  there  is  a  livid  appearance  on  the 
cheeks— ^tf/^  is  near  at  hand. 


PROPHYLAXIS. 

"WOMEN,  during  the  time  of  geftation,  are 
too  apt  to  neglect  the  keeping  their  bowels  open : 
although  this  has  been  confldered  a  matter  of  no 
importance,  it  is,  however,  often  attended  with 
dangerous  confequences,  and  renders  the  difeafes  to 
which  they  are  liable  in  their  lyings-in  much  more 
fevere  and  obftinate  than  they  would  otherwife  be 
if  coftivenefs  were  prevented.  To  obviate  this 
complaint,  the  cautious  ufe  of  fuch  remedies  as  are 
beft  fuited  to  the  iituation  of  thefe  women,  muft  be 
had  recourfe  to,  fuch  as  clyfters,  gentle  laxatives, 
and  that  kind  of  diet  which  tends  to  keep  the 
bowels  open,    fuch  as  vegetables  and  ripe  fruits. 

An 


(    *9    ) 

An  indolent,  fedentary  life  not  only  occafions  the 
bowels  to  remain  in  a  coftive  ftate,  but  may  be  con* 
fidered  as  predifpofing  to  this  difeafej  women 
mould,  therefore,  take  gentle  exercife,  in  the  open 
air,  as  often  as  the  weather  will  permit ;  they  ought 
to  avoid  all  fuch  emotions  of  the  mind  as  greatly 
difturb  and  agitate  their  fyftems,  by  devoting  fome 
part  of  their  time  to  agreeable  company,  and  by 
purfuing  fuch  means  as  will  tend  to  promote  cheer- 
fulnefs :  their  diet  mould  be  light,  nourifhing,  and 
eafy  of  digeftion;  their  cloathing  mould  fet  eafy, 
and  be  fuch  as  they  have  been  accuftomed  to,  and 
that  will  keep  them  moderately  warm.  If  they  are 
troubled  with  naufea,  vomiting,  hyfteria,  and  the 
want  of  fleep,  opium  will  afford  relief,  if  cautioufly 
adminifteredj  but  if,  notwithftanding,  the  irrita- 
bility of  their  fyftems  becomes  increafed,  recourfe 
muft  be  had  to  the  Peruvian  bark,  mild  calybeates, 
and  other  tonics.  The  frequent  ufe  of  the  cold 
bath  during  geftation  has  fometimes  been  attended 
with  the  happieft  effects;  and  it  appears  that  the 
fame  treatment  (if  nothing  forbids)  is  eflential  in 
removing  that  propensity  to  difeafes  which  is  gene- 
rally prefent  in  parturition-,  and  further,  every 
means  muft  be  ufed  that  will  tend  to  obviate  a  ple- 
toric  ftate  of  the  fyftem.     After  parturition,  every 

meafurc 


(     30    ) 

meafure  muft  ftill  be  had  recourfe  to,  that  will  fecure 
the  fafety  of  the  patient ;  therefore,  all  irritating 
caufes  muft  be  avoided,  cheerfulnefs  promoted,  and 
both  body  and  mind  kept  perfectly  quiet,  that  the 
patient  may,  for  a  few  hours,  enjoy  Nature's  fweet 
reftorer,  "  balmy  fleep."  Nor  is  it  of  little  mo- 
ment that  the  bed-room  mould  be  kept  as  clean  and 
neat  as  poffible ;  the  regimen  mould  be  of  a  cooling, 
vegetable  kind,  and.fuch  as  will  not  overload  the 
ftomachi  cool  drinks,  and  other  liquids  of  the 
acidulous  and  antifceptic  kinds  may  be  freely  ufed. 
The  bowels,  at  this  time,  muft  be  well  attended  to, 
that  they  be  kept  open. by  clyfters  and  gentle  laxa- 
tives. Every  principal  caufe  of  difturbance  muft 
be  avoided,  fuch  as  violent  emotions  of  the  mind, 
with  the  rafh  admittance  of  cold  air  to  the  body ; 
cleanlinefs  muft  be  well  attended  to,  for  if  it  is  not, 
contagion*   may  be  produced,   which   has  been 

thought, 

*  It  may  be  fufpe&ed  that  contagious  matter  Is  much  oftener  produced, 
and  in  a  greater  variety  of  difeafes  than  is  commonly  imagined— that 
is,  a  matter  is  generated  or  fecreted  in  veffels  morbidly  active, 
which,  when  applied  to  other  vcfTels,  even  in,  a  found  body,  tends  to  ex- 
cite in  them  a  fimilar  action  to  that  which  originated  itfelf.  Hence  clean- 
linefs is  neceifary  in  all  difeafes;  not  becaufe  the  want  of  it  produces  the 
contagious  matter,  but  becaufe  it  prevents  an  effective  concentration 
of  it.  The  general  principle  of  this  contagious  operation  is  in  analogy 
with  an  infinitude  of  phsenomena  in  the  human  body  depending  upon  this 
general  law  in  the  fyftem — that  the  fluids  in  certain  vessels 

ARE  AT  ONCE  THE  PRODUCT  OF  THOSE  VESSELS,  AND  THB  A3- 
JROPRIATE   STIMULI  TO  THEIR    FURTHER   ACTION. 

ProfefTor  Smith's  M.  S.  Lectures. 


(     5*     5 

thought,  in  every  inftance,  the  caufe  of  puerperal 
fever  ;*  therefore,  a  free  ventilation  of  the  lying-in 
room  is  highly  neceffary  ;  nor  is  the  officious  inter- 
ference of  ignorant  vifitants  to  be  permitted  ;  nei- 
ther is  too  rigid  a  treatment  neceflary  ;  for  in  things 
of  an  indifferent  nature  we  may  indulge  our  pa- 
tients. Every  lying-in  woman  is  to  be  treated  with 
the  greateft  attention  and  the  moft  foothing  indul- 
gence, and  whatever  will  render  her  pains  more 
eafy,  mould  moft  readily  be  granted ;  every  degree 
of  violence  mould  be  carefully  avoided ;  and,  there- 
fore, the  practice  of  tearing  away  the  placenta  can- 
not be  too  highly  condemned,  for  it  is  not  only  a 
cruel  but  hazardous  expedient,  and  at  this  day  is 
generally  condemned  by  the  beft  practitioners,  and 
fnould  not  be  had  recourfe  to  but  in  extreme  danger 
from  floodings,  &c.-j-  The  effect  of  opiates,  gen- 
tle compreffion  of  the  abdomen,  and  afterwards 
increafing  it,  ought  firft  to  be  tried.  If  the  pati- 
ent is  expofed  to  contagion,  every  means  mould 
be  carefully  ufed  that  tend  to  leffen  and  moderate  its 
violence,  or,  if  poffible,  to  render  it  inert.  Fre- 
quent change  of  linen  and  air,  the  Peruvian  bark, 
mild  calybeates,  gentle  exercife,  and  that  kind  of 
diet  which  will  give  ftrength  and  vigor  to  the  fyf- 
tem,  are  to  be  ufed. 

It 

•  Young,  <f  Mawrlccau,  8te. 


(    32    ) 

It  Is  alfo  necefTary  that  every  thing  relative  to 
parturition  mould  be  conducted  in  the  moft  fimple 
manner*,  the  breafts  fhould  be  drawn  in  due  feafon; 
the  abdomen  kept  free  from  conftipation  ;  the  bed- 
room muft  be  well  aired  as  before  mentioned;  the 
diet  light  and  fparing  •,  the  drinks  cooling  and  acidu- 
lous, and  all  kinds  of  fpirituous  liquors  and  cordials 
carefully  avoided,  unlefs  great  debility  has  already 
taken  place ;  for  by  obferving  this  mode  of  treat- 
ment in  lying-in  women,  the  difeafe  (if  it  has  com- 
menced) will  not  only  be  rendered  more  mild,  but 
many  things  may  be  avoided  that  might  otherwife 
be  injurious,  were  the  difeafe  to  take  place. 

If  the  lochia  mould  flow  in  too  great  quantities,, 
the  infufion  of  bark  and  tinct.  rofar.  with  as  much 
dix.  vitriol,  as  will  make  it  agreeable,  may  be  had 
recourfe  to,  together  with  abfolute  reft  in  the  hori- 
zontal polition.  But  if  the  lochia  have  been  long 
retained,  and  there  is  reafon  to  fufpect  they  have 
become  acrid,  it  may  not  be  amifs  to  inject  fbme- 
thing  emollient  and  antifceptic  into  the  uterus. 
Thefe  are  the  moft  general  means  of  preventing 
this  dangerous  and  often  fatal  difeafe.  I  mall  now 
proceed  to  the 


METHOD 


(     33     ) 

METHOD  OF  CURE. 

NO  difeafe  has  more  divided  the  fentiments  of 
Phyficians,  in  regard  to  the  method  of  cure,  than 
that  of  the  puerperal  fever.  The  apparent  indica- 
tions and  contra-indications  of  bleeding,  and  other 
remedies  arifing  from  the  complication  of  inflam- 
matory and  typhus  fymptoms,  the  equivocal  ap- 
pearances of  the  vomiting  and  purging,  whether 
they  be  critical  or  fymptomatic,  and  the  different 
caufes  whence  fymptoms  fimilar  to  each  other  may 
arife  in  pregnant  women;  all  thefe  circumftances 
concur  to  involve  the  fubject  in  great  obfcurity  and 
indecifion :  however,  if  we  carefully  attend  to  the 
feveral  characteristics  of  this  difeafe,  fo  as  to  be  able 
to  diftinguifh  it  from  every  other  puerperal  com- 
plaint, and  obferve  at  the  fame  time  the  ufual  man- 
ner of  its  declination,  our  judgments  may  in  fome 
meafure  be  guided  in  the  method  of  cure  by  the 
falutary  efforts  of  nature. 

The  method  of  cure  which  appears  the  mod  proper 
to  me,  may  be  defcribed  under  two  general  indications. 

I.  To  diminifh  or  take  off  the  fthenic  diathefis. 

II.  To  obviate  the  debility  and  putrefcency  which 
follow,  and  at  the  fame  time  to  moderate  all  trouble- 
fome  fymptoms. 

E  To 


(     34    ) 

To  anfwer  the  firft  intention,  immediate  recourfe 
muft  be  had  to  the  fedative  plan  and  regimen;  a 
principal  mean  in  which  is  blood-letting :  but  of  its 
utility  in  this  difeafe  there  appears  nothing  certain 
in  the  writings  of  Phyficians ;  fome  contending  that 
venefe&ion  is  proper,  others  that  it  is  ufelefs  and 
hazardous ;  but  there  have  been  fome  inftances  of 
critical  haemorrhages,  which  would  feem  to  confirm 
its  utility.  Dr.  Denman  thinks  it  may  fafely  be 
affirmed  from  experience,  that  for  one  who  will  be 
benefited  by  large  bleeding,  a  much  greater  number 
will  be  injured  thereby,  and  that  even  almoft  irre- 
trievably. Nor  can  this  feem  furprifing  when  we 
confider  the  fituation  of  women  in  child-bed :  the 
evacuations  confequent  upon  delivery  are  ufually  fuf- 
ficient  to  diminilh  any  undue  fuperabundance  of  the 
fluids;  and  if,  as  frequently  happens,  the  difeafe 
be  produced  by  too  hafty  a  feparation  of  the  pla- 
centa, the  confequence  of  which  is  generally  a  very 
copious  difcharge  of  blood,  we  can  never  fuppofe 
that  nature  will  be  affifled  in  overcoming  the  febrile 
commotions,  by  the  further  evacuation  of  the  vital 
fluid?  through  the  defect  of  which  fhe  is  now  ren- 
dered unequal  even  to  the  ordinary  fupport  of  the 
animal  ceconomy ;  and  every  practical  Phyfkian  mull 
Joiow  how  much  the  pulfe  finks,  and  what  a  train 


C     35     ) 

of  nervous  fymptoms  is  obferved  to  fucceed  an  ex- 
cefs  of  the  difcharge  above-mentioned :  and,  more- 
over, it  is  an  axiom  in  phyfic,  that  a  remedy  which 
cures  any  diforder,  will  always  prove  fufficient  to 
prevent  it ;  and  therefore,  if  bleeding  were  the  pro- 
per cure  in  the  puerperal  fever,  the  difeafe  ought  to 
have  been  prevented  by  a  large  evacuation  of  blood 
when  that  happened  previous  to  its  feizure.  Expe- 
rience, however,  in  this  as  in  all  other  difeafes,  is 
the  only  unerring  guide  we  can  follow ;  and  whoever 
regulates  his  practice  by  facts  and  obfervation,  will 
be  convinced  that  venefection,  efpecially  in  a  large 
quantity,  is  in  general  very  far  from  being  attended 
with  fuccefs ;  and,  for  my  own  part,  I  think  it  will 
feldom  if  ever  be  proper,  unlefs  in  women  of  active, 
robuft  and  plethoric  habits,  and  in  whom  fometimes 
the  fymptoms  of  inflammation  run  high,  and  even 
in  fuch  perfons,  it  is  not  to  be  repeated  but  with  the 
greateft  caution,  and  when  the  fymptoms  are  moft 
urgent :  Bleeding,  when  ufed  in  proper  circum- 
ftances,  may  palliate  the  fever;  but  that  it  often 
fhortens  the  duration  of  it,  appears  to  be  a  matter  of 
much  doubt:  on  this  account  the  practice  becomes 
{rill  more  fufpicious  and  exceptionable,  when  we 
confider  that  by  venefection  being  improperly  ufed, 
the  patient's  ftrength  may  be  fo  far  reduced  as  not 

to 


(    z*    ) 

to  fupport  the  tedious  diarrhoea  by  which  the  difeafe 
is  generally  removed. 

Whenever  blood  is  to  be  drawn,  it  ought  to  be 
taken  away  at  the  commencement  of  the  diforder, 
and  the  bleeding  mould  not  be  in  large  quantities, 
left  a  dangerous  ftate  of  debility  be  induced  thereby  •, 
for  it  is  worthy  of  remark,  that  whenever  fevers 
incline  to  great  debility,  we  are  to  avoid  favouring 
it,  by  copious  blood-letting.*  Upon  the  whole,  this 
evacuation  promifes  very  little  advantage ;  and  it  has 
been  afterted  by  fome,  that  the  difeafe  is  never  mi- 
tigated by  it—that  the  pulfes  become  lower  after 
bleeding,  although  the  blood  be  covered  with  a  bufiy 
coat ;  therefore,  particular  attention  muft  be  paid  to 
the  ftate  of  the  fymptoms  before  we  make  ufe  of 
this  remedy,  and  efpecially  to  that  of  the  pulfe.  Nor 
is  the  duration  of  the  complaint  to  be  neglected, 
for  this  and  many  other  circumftances  muft  be  at- 
tended to  before  the  lancet  is  ufed. 

The  ftate  of  the  bowels  is  next  to  be  attended 
to,  and  if  they  require  opening,  it  muft  be  done 
either  by  clyfters  or  laxative  medicines,  fuch  as  the 
neutral  falts,  or  the  oleum  ricini;  which  muft  be 
repeated  till  a  free  difcharge  from  the  bowels  is  ob- 
tained; for  ftools  muft  at  all  events  be  procured,  as 

on 

•  Cullen, 


(     37     ) 

oh  thefe  at  firft  are  founded  our  greateft  hopes  of 
fuccefs ;  for,  by  emptying  the  firft  paffages,  all  dif- 
tenfion  from  the  contained  foeces  is  taken  off,  flatu- 
lence leffened,  irritation  from  the  fceces  avoided, 
and  fome  degree  of  freedom  is  given  to  the  circulat- 
ing fluids  of  the  parts  affected:  but  this  muft  be 
done  in  the  moft  gentle  manner,  and  by  fuch  medi- 
cines as  will  not  create  ficknefs,  as  the  faline  purges 
or  emulfion  of  caftor  oil.  The  firft  evacuations  are 
generally  foetid-,  but,  if  afterwards  they  become  lefs 
offenfive,  and  the  patient  feels  herfelf  generally  re- 
lieved, me  commonly  falls  into  a  fleep,  which  is  fuc- 
ceeded  by  a  gentle  perfpiration.  "Whatever  pro- 
motes this  perfpiration  (which  ought  not  to  be  pro- 
fufe  or  kept  up  by  fuch  medicines  as  may  either  pro- 
duce coftivenefs  or  heat  the  fyftem)  fhould  be  admi- 
nistered j  the  moft  proper  are  the  ipecacuanha,  tar- 
tar emetic,  or  antimonial  wine,  in  fmall  dofes,  every 
fecondor  third  hour,  with  the  addition  of  opium,  and 
in  the  intervals  the  faline  mixtures  will  be  found  ad- 
vantageous: thefe  alleviate  pain,  determine  the  fluids 
externally,  are  in  a  degree  diuretic  and  antifceptic, 
and  this  without  aftringency  or  fanguiferous  ftimu- 
btion.  A  determination  to  the  fkin  may  alfo  be 
folicited  by  fmall  and  repeated  dofes  of  lukewarn 
diluents,    as  vinegar  whey,   lemonade,   toaft  and 

water, 


(     38     ) 

water,  a  flight  infufion  of  malt,  or  things  of  a  fimi- 
Jar  nature. 

Stimulants,  and  the  heating  regimen,  although 
they  may  be  ufed  for  the  purpofe  of  rendering  the 
cold  ftage  fhorter,  are  very  improper  and  injurious, 
and  ought  therefore  to  be  rejected,  efpecially  thofe 
medicines  which  are  called  emmenagogue. 

The  vis  vit^e  is  to  be  fupported  as  much  in  this  as 
in  any  typhus  fever-,  cool  air  is,  therefore,  of  fer- 
vice,  and  cleanlinefs,  as  before  noted,  muft  efpeci- 
ally be  attended  to;  for  which  purpofe  the  bed- 
clothes and  body  linen  mould  be  frequently  changed. 
If  the  vomiting  mould  be  troublefome,  and  fuch  as 
feems  to  arife  from  a  fuperabundance  of  bile,  mild 
emetics  and  laxatives  have  been  recommended  to 
reftrain  it:*  and  if  the  fymptoms  of  inflammation 
are  not  prefent,  a  fmall  quantity  of  opium  may  be 
given  as  foon  as  the  vomiting  will  permit,  to  prevent 
further  ftimulus  -,  for  if  the  vomiting  is  not  reftrain- 
ed,  or  its  violence  leflened,  difagreeable  confequences 
may  enfue  from  the  ftraining,  &c.  by  the  protrufion 
of  the  womb,  the  ligaments  of  which  are  now  in  a 
relaxed  ftate.     The  moft  proper  drinks  are  thofe 

which 
>i 

*  In  the  Hotel  Dieu,  at  Paris,  fix  or  eight  grains  of  Ipecacuanha  exhibited 
early,  and  repeated  twice  a  day  as  long  as  neceffary,  have  been,  it  is  faid, 
attended  with  remarkable  fuccefs. 

Macbride  and  Lind  have  obferved,  that  vomiting  is  very  ferviceable  in 
all  fevers  ariling  from  contagion. 


(     39    ) 

which  are  mild,  refrigerant  and  diluent;  but  the  ufe 
of  all  fpirituous  and  fermented  liquors  muft  be  pro- 
hibited during  the  firft  or  inflammatory  ftage  of  the 
difeafe. 

If,  in  purfuing  this  mode  of  treatment,  there  ap- 
pears to*  be  a  change  for  the  better,  we  muft  next 
attend  to  the  ft  ate  of  the  inteftines,  and  endeavour 
to  reftore  their  tone  and  vigor.  A  free  admiffion  of 
cool  air,  with  the  ufe  of  the  bark,  and  exercife  in 
fair  weather,  will  generally  be  fufficient  to  remove 
any  remaining  indifpofition.  But,  on  the  other  hand, 
if  the  difeafe  does  not  remit,  but  appears  to  increafe, 
and  becomes  more  violent,  verging  to  putridity, 
recourfe  muft  be  had  to  our  fecond  indication,  which 
is  to  obviate  the  debility  and  putridity  about  to  take 
place. 

Of  all  the  fymptoms  ufually  connected  in  this 
ftage  of  the  difeafe,  the  moft  remarkable  and  troui, 
blefome  is  that  of  diarrhoea,  which,  in  the  begin- 
ning of  the  complaint,  is  not  injurious,  and  ought 
rather  to  be  promoted  than  checked-,  but  if  immo- 
derate, it  fhouldbe  fomewhat  reftrained  by  clyfters,* 
with  opium,  and  fuch  medicines  as  have  a  gentle 
reftringent    operation  j    the  Japonic  confection  is 

ufeful 

•  Which  fliould  be  emollient,  diluting  and  nutrit'ou;,  compofed  of  brothi, 
beef-tea,  cammomile  inlufion  with  oil,  and  i1r.prc5r.aced  with  fixed  air  or 
ytart. 


(     40     ) 

ufeful  at  this  time;  the  method  of  treatment  juft 
defcribed  muft  efpecially  be  ufed.  If  the  ftrength  of 
the  patient  mould  be  greatly  reduced  by  the  diarrhoea, 
it  is  cautioujly  to  be  checked,  as  it  oftentimes  proves 
critical  and  falutary.*  By  correcting  the  ftate  of 
the  fluids,  we  may  render  the  irritating  caufe  in  the 
inteftines  lefs  active,  by  which  thofe  profufe  evacua- 
tions become  retrained. 

Epifpaftics  have  been  faid  to  be  of  fervice  in  this 
difeafe,  when  employed  after  venefection ;  but  it  is 
probable  they  can  be  of  no  other  fervice  in  this  fever 
than  by  removing  topical  pain. 

Although  fpirituous  liquors  and  a  generous  diet 
are  injurious  in  the  commencement  of  this  difeafe, 
they  now  become  very.neceflary.  Wine  and  water, 
cinnamon  water,  and  other  cordials  may  alfo  be 
given.  Befldes  thefe  remedies,  the  Peruvian  bark 
.and  columbo-root,  either  alone  or  joined  with  aro- 
matics  and  opiates,  may  be  employed,  which,  in 
relieving  this  difeafe,  have  been  very  much  ex- 
tolled, and  defervedly  fo,  although  they  fometimes 
fail.  If  the  diarrhoea  fhould  yet  continue,  ftill 
more  powerful  aftringents  feem  to  be  indicated,  fuch 

as 

*  When  the  diarrhcea  becomes  critical  and  feems  to  be  the  means  of 
freeing  the  fyftem  from  puerperal  fever,  may  we  not  fufpedt  an  analogy  in 
the  ftate  of  the  vefiels  of  the  inteftines  with  that  of  the  urethra,  in 
thofe  cafe:  of  mild  gonorrhoea  where  the  difeafe  goes  off  fponianeoufly  ? 


(     4i     ) 

as  the  hsematoxylum,  kino,  and  others  of  this  fort. 
-*-Can  we  expect  any  advantage  from  the  cold  bath, 
applied  either  by  the  fponge  or  in  form  of  a  fhower, 
or  applied  in  any  other  way  when  great  debility 
prevails  ?  An  application  like  this  is  certainly  wor- 
thy of  attention,  as  it  has  been  thought  of  fervice 
in  the  cure  of  typhus  fever,*  and  I  am  informed, 
is  the  common  practice  at  Vienna  and  fome  parts  of 
the  Weft-Indies. 

It  is  further  to  be  obferved,  that  the  fuccefs  in 
the  means  ufed  for  the  removal  of  this  difeafe,  de- 
pends principally  upon  the  immediate,  early  and 
conftant  ufe  of  the  remedies  before  mentioned,  for 
we  muft  have  recourfe  to  them  even  before  any 
remiflion  has  appeared,  as  fhortly  after  the  difeafe 
rejects  aftiftance  from  all  medicines,  and  fpeedily 
terminates  in  death.  Hence,  whenever  the  vomit- 
ing becomes  very  violent  and  appears  to  aggravate 
the  other  fymptoms,  we  muft  have  immediate  re- 
courfe to  the  faline  draughts ;  and  if  thefe  mould 
afford  no  relief,  the  infufion  of  columbo-root  and 
liquid  laudanum  muft  be  tried :  and  whether  the 
faline  draughts  are  of  fervice  or  not,  we  muft  make 
ufe  of  the  laft  mentioned  remedies,  for  from  thefe 
we  may  expect  relief  with  fome  degree  of  certainty. 
F  To 

*  Gregory. 


(       42       ) 

To  relieve  the  pains  of  the  abdomen,  emollient  cata- 
plafms  or  fomentations  are  generally  ufed  with  fuc- 
cefs;  but  if  they  mould  fail  of  affording  relief, 
epifpaftics,  the  rubifacients,  camphor  and  opium 
will  not  be  ufed  in  vain. 

To  obviate  or  remove  the  dyfpncea,  epifpaftics, 
applied  between  the  moulders,  are  always  of  fervice, 
as  alfo  the  fpermacasti  mixture. 

It  is,  after  all,  very  evident,  that  the  nature  of 
the  puerperal  fever,  and  much  more  the  method  of 
treating  it,  are  not  well  underftood. 

To  what  has  been  faid  we  may  add,  that  the  pa- 
tient recovering  from  this  difeafe  mould  be  treated 
as  a  convalefcent  from  any  other  fever ;  and  if  me 
mould  not  be  quickly  reftored  to  health,  the  cold 
bath  and  various  other  tonics  may  become  necef- 
fary. 

FINIS, 


errata; 

Page  2 1,  line  6,  for 6  does,'  read e  do.5 

Page  25,  line  18,  for  '  abdomen,'  read  <  bowels.' 


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